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Effort–reward imbalance and long-term benzodiazepine use: longitudinal findings from the CONSTANCES cohort
  1. Guillaume Airagnes1,2,3,4,
  2. Cédric Lemogne1,2,5,
  3. Sofiane Kab3,
  4. Nicolas Hoertel1,2,5,
  5. Marcel Goldberg3,
  6. Morten Wahrendorf6,
  7. Johannes Siegrist7,
  8. Yves Roquelaure8,
  9. Frédéric Limosin1,2,5,
  10. Marie Zins2,3,4
  1. 1 Department of Psychiatry and Addictology, AP-HP, Hôpitaux Universitaires Paris Ouest, Paris, France
  2. 2 Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
  3. 3 UMS 011, Population-based Epidemiological Cohorts, Inserm, Villejuif, France
  4. 4 UMR 1168, VIMA, Inserm, Villejuif, France
  5. 5 U1266, UMR-S 1266, Institut de Psychiatrie et Neurosciences de Paris, Inserm, Paris, France
  6. 6 Centre for Health and Society,Institute of Medical Sociology, Medical Faculty, University of Düsseldorf,Universitätsstrasse 1, 40225 Düsseldorf, Germany
  7. 7 Senior professorship on work stressresearch, Medical Faculty, University of Düsseldorf, Germany, Düsseldorf, Germany
  8. 8 UMR 1085, Ester, Irest Inserm, Université d’Angers, Angers, France
  1. Correspondence to Dr Guillaume Airagnes, Centre Ambulatoire d'Addictologie, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France; guillaume.airagnes{at}


Objectives To examine the association between effort–reward imbalance and incident long-term benzodiazepine use (LTBU).

Methods We included 31 077 employed participants enrolled in the French population-based CONSTANCES cohort between 2012 and 2014 who had not undergone LTBU in the 2 years before enrolment. LTBU was examined using drug reimbursement administrative databases. The effort–reward imbalance was calculated in quartiles. We computed ORs (95% CIs) for LTBU according to effort–reward imbalance over a 2-year follow-up period. We adjusted for age, gender, education, occupational grade, income, marital status, tobacco smoking, risk of alcohol use disorder, depressive symptoms and self-rated health.

Results Over the 2-year follow-up, 294 (0.9%) participants experienced incident LTBU. In the univariable analysis, effort–reward imbalance was associated with subsequent LTBU with ORs of 1.79 (95% CI 1.23 to 2.62) and 2.73 (95% CI 1.89 to 3.95) for the third and fourth quartiles, respectively, compared with the first quartile. There was no interaction between effort–reward imbalance and any of the considered variables other than tobacco smoking (p=0.033). The association remained significant in both smokers and non-smokers, with higher odds for smokers (p=0.031). In the fully adjusted model, the association remained significant for the third and fourth quartiles, with ORs of 1.74 (95% CI 1.17 to 2.57) and 2.18 (95% CI 1.50 to 3.16), respectively. These associations were dose dependent (p for trend <0.001).

Conclusions Effort–reward imbalance was linked with incident LTBU over a 2-year follow-up period after adjustment for sociodemographic and health-related factors. Thus, screening and prevention of the risk of LTBU should be systematised among individuals experiencing effort–reward imbalance, with special attention paid to smokers.

  • addictive behaviour/addiction
  • depression
  • drug misuse
  • longitudinal studies
  • occupational health

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  • Contributors GA, CL and MZ designed the study. GA wrote the first draft of the article. MG and MZ collected the data. GA managed the literature searches. GA and SK undertook the statistical analysis. All the authors participated in the interpretation of the results, revised the draft critically for important intellectual content and approved the final article.

  • Funding CONSTANCES is accredited as a National Infrastructure for Biology and Health by the governmental Investissements d’Avenir Programme and was funded by the Agence Nationale de la Recherche (ANR-11-INBS-0002 Grant). CONSTANCES also receives funding from MSD, AstraZeneca and Lundbeck, managed by INSERM-Transfert. This study has received a funding from the Interministerial Mission for Combating Drugs and Addictive Behaviors (Mission Interministérielle de Lutte contre les Drogues et les Conduites Addictives, MILDECA).

  • Competing interests GA has received speaker and consulting fees from Lundbeck and Pfizer. CL has received speaker and consulting fees from Daiichi-Sankyo, Janssen, Lundbeck, Otsuka Pharmaceuticals and Euthérapie-Servier. FL has received speaker and consulting fees from Euthérapie-Servier, Janssen, Lundbeck and Otsuka Pharmaceuticals. SK, NH, MG, MW, JS, YR and MZ have nothing to declare. There are no other relationships or activities that could appear to have influenced the submitted work. None of the authors are salaried by the funders of the CONSTANCES cohort. The funders did not have any role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Personal health data underlying the findings of our study are not publicly available due to legal reasons related to data privacy protection. CONSTANCES has a data sharing policy, but before data transfer, a legal authorisation has to be obtained from the Commission Nationale de l’Informatique et des Libertés, the French data privacy authority. The CONSTANCES email address is